Tuning mobile phase properties to improve empty and full particle separation in adeno-associated virus productions by anion exchange chromatography.

In the past decade, recombinant adeno-associated virus (rAAV) has gained increased attention as a prominent gene therapy technology to treat monogenetic diseases. One of the challenges in rAAV production is the enrichment of full rAAV particles containing the gene of interest (GOI) payload. By adjusting the mobile phase properties of anion-exchange chromatography (AEX), it was demonstrated that empty and full separation of rAAV was improved in monolith based preparative AEX chromatography. When compared to the baseline method using NaCl, the use of tetraethylammonium acetate (TEA-Ac) in the AEX mobile phase resulted in enhanced resolution from 0.75 to 1.23 between "Empty" and "Full" peaks by salt linear gradient elution, as well as increased the percentage of full rAAV particles from 20% to 36% and genome recovery from 59% to 62%. Furthermore, a dual wash plus step elution AEX method was developed. Wherein, the first wash step harnesses TEA-Ac to separate empty and full capsids, which is followed by a second wash step that ensures no TEA-Ac salt is carried over into AEX eluate. The resulting optimized AEX purification method has the potential to be adapted for manufacturing and purification processes involving various rAAV production platforms that experience empty and full rAAV separation challenges.

Assessment of musculoskeletal pain and surgical ergonomic parameters among members of the American Society of Pediatric Otolaryngology.

OBJECTIVES: To assess rates of self-reported work-related pain and knowledge of ergonomic principles among fellowship trained pediatric otolaryngologists within the American Society of Pediatric Otolaryngology (ASPO). We hypothesized that pediatric otolaryngologists experience rates of musculoskeletal pain and injury similar to what has been reported among adult otolaryngologists and other surgical subspecialties. METHODS: An IRB-approved survey was distributed to members of ASPO through email listserv. Collected variables included surgeon demographic information, practice settings, surgical volume, procedure types, work-related musculoskeletal pain-related metrics, modifying factors, and knowledge/attitudes on surgical ergonomics. RESULTS: A total of 685 ASPO members were approached via email, of which 435 opened the survey email and 118 attending pediatric otolaryngologists completed the survey (response rate 27%). In all, 78% of respondents reported current or prior pain and/or injury attributed to performing surgery, 20% higher than that reported in the previous ergonomics survey of ASPO members in 2012. The most affected areas were neck/cervical spine (63%), shoulders/arms (44%), lower back/lumbar spine (36%), and hands/wrist (31%). Half of the respondents were diagnosed with musculoskeletal condition(s) attributed to performing surgery. Two-thirds required treatment (62% pharmacologic only, 9% pharmacologic and surgical intervention) for their work-related pain. Leveraging intermittent pauses during surgical procedures to adjust body position was the most reported method of addressing pain in the operating room. Only 21% report ever having received ergonomic training during their training or career. CONCLUSION: Musculoskeletal pain associated with performing pediatric otolaryngology procedures is highly prevalent and has not attenuated despite increased awareness of surgical ergonomics. Results from this study underscore the need to develop standardized surgical ergonomics curricula for pediatric otolaryngologists and trainees.

A Survival Analysis of Pediatric Tonsillar Malignancies and Review of a Rare Case.

OBJECTIVE: To examine the survival of pediatric tonsillar cancer patients and review a rare case of pediatric tonsillar cancer. METHODS: Pediatric patients in the Surveillance, Epidemiology, and End Results (SEER) database were included from 1973 to 2014 based on a diagnosis of tonsillar malignancy using the ICD O-3 tonsil primary site codes of: C09.0, C09.1, C09.8, and C09.9. Patients were included from birth-18 years. Survival analysis was performed using Kaplan-Meier analysis. Additionally, a case of pediatric natural killer (NK) cell tonsillar lymphoma diagnosed and treated at the Nemours Children's hospital in Orlando, Florida is presented. RESULTS: One hundred forty-one cases of tonsil cancer were identified. The mean age at diagnosis was 9.9 years (SD: 5.1, range: 0.0 (months)-18.0). Ninety five (67.4%) patients were male and 116 (82.3%) had unilateral malignancies. Burkitt lymphoma (32.6%) followed by diffuse large B-cell lymphoma (DLBCL) (27.0%) were the two most common histological types of tonsillar cancers. 79.4% of patients received chemotherapy and 81.6% received surgery as a part of their care. The 5-year disease-specific survival rate was >90% for patient cohorts diagnosed from 1984 to 1993, 1994-2003, and 2004-2014 as compared to 64% for patients diagnosed from 1973 to 1983 (p = 0.01). CONCLUSIONS: Survival rates for pediatric patients with tonsillar cancer are excellent. Pediatric primary tonsil cancer occurred most commonly in adolescent males and usually presents as a unilateral mass. Lymphoma remains the predominant histological type of cancer. Most patients are likely to receive surgery and chemotherapy.

Pediatric head and neck fibrosarcomas: A demographical, treatment, and survival analysis and review of a rare case.

OBJECTIVE: To examine pediatric head and neck fibrosarcoma cases and review the demographics, management, and survival for these patients. METHODS: Pediatric patients in the Surveillance, Epidemiology, and End Results (SEER) database were included from 1973 to 2014 based on a diagnosis of a head and neck fibrosarcoma using ICD-O-3 head and neck primary sites and histology codes. Patients were included from birth-18 years of age. Additionally, a pediatric case of a head and neck infantile fibrosarcoma treated at the Nemours Children's hospital in Orlando, Florida is presented. RESULTS: One hundred-thirteen pediatric head and neck fibrosarcomas were identified within the SEER database over the study period. The mean age at diagnosis was 9.8 years (SD: 6.2, range: 0.0-18.0). The mean age at diagnosis for infantile fibrosarcomas was 1.7 years (SD: 3.2, range: 0.0-12.0). Fifty-one (45.1%) patients were female. A majority (N = 67, 59.3%) of patients had dermatofibrosarcoma followed by 18 (15.9%) who had infantile fibrosarcomas. Nearly all patients (N = 107, 94.7%) received surgical intervention. 27.8% of patients with an infantile fibrosarcoma received chemotherapy as a part of their care compared to 1.5% of patients with a dermatofibrosaroma (p = .004). The 5-year disease-specific survival was 97%. CONCLUSIONS: Pediatric patients with head and neck fibrosarcomas are most likely to present in Caucasian males or females during late childhood or early adolescence. Infantile fibrosarcomas present in pediatric patients at a much earlier age. Surgical management is common for pediatric head and neck fibrosarcomas. Additionally, chemotherapy may be used for infantile fibrosarcomas of the head and neck. Survival rates for pediatric patients with a head and neck fibrosarcoma are excellent.

Communication Among Melanoma Family Members.

Interventions to improve communication among family members may facilitate information flow about familial risk and preventive health behaviors. This is a secondary analysis of the effects of an interactive website intervention aimed at increasing communication frequency and agreement about health risk among melanoma families. Participants were family units, consisting of one family member with melanoma identified from a previous research study (the Case) and an additional first degree relative and a parent of a child 0-17. Family triads were randomized to receive access to the website intervention or to serve as control families. Family communication frequency and agreement about melanoma prevention behaviors and beliefs were measured at baseline and again at 1 year post randomization. Intervention participants of all three types significantly increased the frequency of communication to their first degree relatives (Parents, siblings, children; range = 14-18 percentage points; all p < .05). At baseline, approximately two-thirds of all three family members talked with at least some member of the family about cancer risk. Agreement between Cases and First Degree Relatives and between Cases and Parents increased from pre to post intervention in the intervention participants compared to the control participants (p < .05). These findings provide support for interventions to improve family communication about cancer risk.

Sinonasal Quality of Life in Children After Outfracture of Inferior Turbinates and Submucous Inferior Turbinoplasty for Chronic Nasal Congestion.

Importance: Chronic nasal congestion often persists in children despite empirical treatment using intranasal corticosteroids, systemic antihistamines, and/or leukotriene receptor antagonists. Symptoms are often reported even with negative results of skin or blood allergy testing. Inferior turbinoplasty has been effective in adults and children, but outfracture of inferior turbinates in children is rarely reported, as is use of validated quality-of-life measures to quantify improvements after intervention. Effective use of these 2 procedures for treating chronic nasal congestion may reduce the need for medication and improve sinonasal quality of life. Objective: To quantify changes in sinonasal quality of life for children after outfracture of inferior turbinates and concomitant submucous microdebrider inferior turbinoplasty for chronic nasal congestion. Design, Setting, and Participants: A case series with planned data collection was conducted in an ambulatory pediatric otolaryngology clinic among 43 patients with chronic nasal congestion who underwent surgical intervention between January 1, 2014, and May 31, 2015. Exposures: Microdebrider submucous inferior turbinoplasty (without bony resection) and outfracture of inferior turbinates. Main Outcomes and Measures: Demographics and medication use before and after the procedure were reviewed. Scores on the Sinus and Nasal Quality of Life Survey (SN-5) and quality-of-life scores were collected at baseline, 4 to 6 weeks after the procedure, and more than 6 months after the procedure. Results: Among the 43 patients (14 girls and 29 boys; mean age, 11.2 years [range, 4.8-17.6 years]), every domain showed significant improvements in scores on the Sinus and Nasal Quality of Life Survey and quality-of-life scores 1 to 2 months after the proecdure: sinus infection (-2.55; 95% CI, 1.85-3.26), nasal obstruction (-3.51; 95% CI, 2.88-4.14), allergy symptoms (-2.14; 95% CI, 1.43-2.86), emotional distress (-2.37; 95% CI, 1.68-3.06), activity limitation (-1.70; 95% CI, 1.14-2.25), and overall quality of life (3.72; 95% CI, 2.95-4.48). At long-term follow-up, improvement was maintained in all categories. Significant improvements in SN-5 and quality-of-life scores correlated with proportional decreased reporting of snoring after the procedure (33 [77%] vs 1 [2%]; absolute reduction, 75%; 95% CI, 62%-88%), as well as nasal congestion (41 [95%] vs 1 [2%]; absolute reduction, 93% ; 95% CI, 85%-100%), and rhinorrhea (44 [41%] vs 1 [2%]; absolute reduction, 42%; 95% CI, 27%-57%). The proportion reporting use of intranasal corticosteroids (25 [58%] vs 2 [5%]; absolute reduction, 50%; 95% CI, 39%-71%), antihistamines (27 [63%] vs 1 [2%]; absolute reduction, 61%; 95% CI, 46%-75%), and leukotriene receptor antagonists (13 [30%] vs 0; absolute reduction, 30%; 95% CI, 16%-44%) also decreased. Conclusions and Relevance: Concomitant outfracture and submucous microdebrider inferior turbinoplasty improves quality of life in children with chronic nasal congestion and can reduce use of daily medication.

Comparing incidence of emergence delirium between sevoflurane and desflurane in children following routine otolaryngology procedures.

BACKGROUND: Emergence delirium (ED) is a state of aggressive agitation that can occur temporarily in the process of emerging from anesthesia in children exposed to volatile or intravenous anesthetics. Emergence delirium is typically assessed using the published and validated Pediatric Emergence Delirium (PAED) Scale. Due to some variation in properties between sevoflurane and desflurane for maintenance of anesthesia after standard sevoflurane induction, we designed a prospective study to examine potential differences in emergence behavior and incidence of ED in children undergoing elective ear-nose-throat surgery. METHODS: Forty-six children aged 12 months-7 years were randomly assigned to receive either sevoflurane (N.=23) or desflurane (N.=23) for maintenance of general anesthesia. All patients were extubated awake in the OR, and upon arrival in the PACU, PAED scores were assessed every 15 minutes until discharged. In addition to PAED scores, time to tracheal extubation, emergence behavior, pain scores, and recovery complications were recorded. RESULTS: We found no significant difference in incidence of ED or peak PAED scores between sevoflurane and desflurane groups (12 [0-18] versus 12 [0-20]; P=0.79). There were no significant differences between desflurane and sevoflurane with respect to incidence of adverse events, such as nausea, vomiting, laryngospasm, or excessive secretions. CONCLUSIONS: In conclusion, the use of desflurane for maintenance of anesthesia did not significantly affect the incidence or duration of ED when compared to sevoflurane. However, desflurane did not demonstrate any increase in adverse events, which may support its routine use in this patient population.

Perspectives on neonatal and infant tracheostomy.

Neonates and infants may need a tracheostomy for many different reasons, ranging from airway obstruction to a requirement for long term mechanical ventilator support. Here, we present the pathophysiology of the many congenital and acquired conditions that might be managed with a tracheostomy. Decisions about tracheostomy demand consideration of not only the benefits, but also the potential side-effects, which may differ in the short and long term and may be attributable to underlying conditions as well as the tracheostomy. Evaluation of potential advantages of tracheostomy will influence decisions about optimal timing. In many cases, an infant may 'graduate' from dependence on a tracheostomy and resume a natural airway, although some will require reconstructive airway surgery.

Infantile Fibrosarcoma With NTRK3-ETV6 Fusion Successfully Treated With the Tropomyosin-Related Kinase Inhibitor LOXO-101.

Infantile fibrosarcoma (IFS) is a rare pediatric cancer typically presenting in the first 2 years of life. Surgical resection is usually curative and chemotherapy is active against gross residual disease. However, when recurrences occur, therapeutic options are limited. We report a case of refractory IFS with constitutive activation of the tropomyosin-related kinase (TRK) signaling pathway from an ETS variant gene 6-neurotrophin 3 receptor gene (ETV6-NTRK3) gene fusion. The patient enrolled in a pediatric Phase 1 trial of LOXO-101, an experimental, highly selective inhibitor of TRK. The patient experienced a rapid, radiographic response, demonstrating the potential for LOXO-101 to provide benefit for IFS harboring NTRK gene fusions.

Chronic nasal dysfunction in children: Allergic rhinitis? Infectious? What to do if neither?

PURPOSE OF REVIEW: To review challenges in the diagnosis, work-up, and management of healthy children who present to the otolaryngologist with nasal dysfunction. Common symptoms include chronic nasal congestion, with or without rhinorrhea, with or without previous empirically treated 'allergic rhinitis' and/or 'sinus' infection. Symptoms are often unresolved despite chronic use of intranasal steroid, antihistamine, and/or leukotriene receptor antagonists. RECENT FINDINGS: There are no published studies addressing nasal symptoms in children who test negative for allergies yet report persistent nasal obstruction, congestion, and/or rhinorrhea. Recent publications continue to address efficacy of medical and/or surgical treatment for allergic rhinitis or acute/chronic rhinosinusitis. Best practice for children who 'fail' medical therapy but have impaired quality of life because of nasal dysfunction remains unknown. SUMMARY: Chronic nasal symptoms are common in childhood despite daily treatment using intranasal steroid, antihistamines, and/or leukotriene receptor antagonist therapies. Diet and dietary habit history should be included during evaluation and differential diagnosis as excessive dairy and sugar may contribute to chronic symptoms. Children who fail medical therapy for persistent nasal symptoms, allergic or not, should be referred and considered for outfracture of inferior turbinates and inferior turbinoplasty. Turbinate reduction procedures have demonstrated significant improvement in all domains of SinoNasal Quality of Life as measured by 'SN-5' survey.

Vocal cord paralysis and Dysphagia after aortic arch reconstruction and Norwood procedure.

OBJECTIVES: To determine the incidence of vocal cord (VC) paralysis and dysphagia after aortic arch reconstruction, including the Norwood procedure. SETTING: Tertiary children's hospital. STUDY DESIGN: Retrospective cohort. METHODS: Database/chart review of neonates requiring Norwood or arch surgery between January 2005 and December 2012. Demographics, postoperative VC function, dysphagia, need for gastrostomy tube and/or tracheotomy, and long-term follow-up were reviewed. RESULTS: One hundred fifty-one consecutive subjects (96 Norwood, 55 aortic arch) were reviewed. Median age at repair was 9 days (interquartile range [IQR], 7-13) for Norwood and 24 days (IQR, 12-49) for arch reconstruction (P < .001). Documentation of VC motion abnormality was found in 60 of 104 (57.6%) subjects and unavailable in 47 (16 without documentation and 31 who died prior to extubation). There were no significant differences in proportions of documented VC motion (P = .337), dysphagia (P = .987), and VC paralysis (P = .706) between the arch and Norwood groups. Dysphagia was found in 73.5% of Norwood and 69.2% of arch subjects who had documented VC paralysis. Even without unilateral VC paralysis (UVCP), dysphagia was present (56% Norwood, 61% arch). Overall, 120 of 151 (79.5%) required feeding evaluation and a modified feeding regimen. Gastrostomy was required in 31% of Norwood and 23.6% of arch reconstruction overall. To date, mortality in this series is 55 of 151 (36.4%) patients. Of those with VC paralysis, only 23 (22%) had any otolaryngology follow-up after discharge from surgery. More than 75% with VC paralysis with follow-up after hospital discharge had persistent VC paralysis 11.5 months after diagnosis. CONCLUSION: There is high incidence of UVCP and dysphagia after Norwood and arch reconstruction. Dysphagia was highly prevalent in both groups even without UVCP. Preoperative discussion on vocal cord function and dysphagia should be considered.

Long-term outcome of once daily nasal irrigation for the treatment of pediatric chronic rhinosinusitis.

OBJECTIVES/HYPOTHESIS: Chronic rhinosinusitis(CRS) results in significant morbidity and health care expenditure. Safety and efficacy of nasal irrigation use in the treatment of pediatric CRS have been demonstrated, but long-term outcomes are unknown. We reviewed characteristics and treatment outcomes after 6 weeks of once daily nasal irrigation in pediatric CRS based on computed tomography (CT) scans, and summarized parental reports of subsequent use of nasal irrigation for recurring symptoms STUDY DESIGN: Retrospective cohort study and cross-sectional survey. METHODS: Review and survey of 144 pediatric CRS patients diagnosed between July 2003 and January 2012. RESULTS: One hundred four patients were reviewed. Mean age was 8.0 years, and 65.4% were male. Presenting symptoms included congestion (95.2%), cough (79.8%), rhinorrhea (60.6%), headache (48.1%), and fatigue (40.4%). Comorbidities included positive allergy test (50%), asthma (57.3%), and gastroesophageal reflux disease (28.2%). After 6 weeks, 57.7% of patients reported complete resolution of symptoms. Reductions in Lund-Mackay CT scores were 4.14 and 4.38 on the left and right sides, respectively (P < .001). Of the 54 parents who completed the prospective surveys, 53.7% reported using irrigation again in the past 12 months (median = 1, interquartile range = 3). Only nine patients underwent functional endoscopic sinus surgery (FESS) after the initial 6 weeks. Patients requiring FESS were, on average, 3.6 years older than those who did not receive FESS (P = 0.0005). Median length of follow-up was 48 months (range = 20-113). There were no significant differences in age, Lund-MacKay score changes, and symptom resolution proportions between those who completed the survey and those who did not. CONCLUSIONS: Nasal irrigation is effective as a first-line treatment for pediatric CRS and subsequent nasal symptoms, and reduces the need for FESS and CT imaging. LEVEL OF EVIDENCE: 2b.

Reducing disposable equipment waste for tonsillectomy and adenotonsillectomy cases.

Large amounts of waste in hospitals are generated in the operating rooms from disposable surgical supplies. Tonsillectomy/adenotonsillectomy (T&A) cases use many disposable supplies that are not recyclable. It is critical to reduce disposable waste, as such waste directly affects the environment and increases health care costs. The authors noticed a difference between the number of disposable items prepared, available, but almost never used, for each tonsillectomy case between a children's hospital setting and a university ambulatory surgery center setting. The aims were the following: (1) identify what disposable medical supplies were unnecessarily opened for each case, (2) eliminate all disposable medical waste that was not critical to the case in both settings, and (3) determine the cost reduction at both hospital and surgery center facilities by revising the current disposable instruments/supplies pulled for tonsillectomy cases. The authors report projected cost savings and reduction in waste for one children's hospital and nationally based on their waste reduction.

Safer radiologic imaging of otolaryngologic disease in children.

The use of medical imaging is commonplace in children with otolaryngologic disease, with a not insignificant and increasing exposure to ionizing radiation from such diagnostic imaging. Radiation exposure imparts potential cancer risk, particularly in children, who have long life expectancies and are more sensitive to the adverse effects of ionizing radiation. We summarize these issues, with a focus on computed tomography (CT) in children. The otolaryngologist plays a key role optimizing the use and minimizing the risk of diagnostic imaging in children by ordering the correct test at the best time for the right reasons. In concert with radiology colleagues and informed parents, we can improve the safety of radiologic imaging for the children we diagnose and treat.

Wire grill brush bristle as an unusual foreign body: report of two pediatric cases.

Wire grill brushes are commonly used for cleaning grill grates. Accidental ingestion of a wire bristle from a grill-cleaning brush is a rarely reported foreign body, with only three prior case reports. Although scarce in the literature, we encountered two pediatric cases at the regional children's hospital within 1 year. By presenting these two cases, our goal was to raise awareness of this potentially hazardous foreign body. Additionally, we raise a consumer safety issue associated with the use of wire grill-cleaning brushes as there are currently no ingestion hazard warnings on these products. Laryngoscope,, 2011.

Safety and efficacy of once-daily nasal irrigation for the treatment of pediatric chronic rhinosinusitis.

OBJECTIVES/HYPOTHESIS: To compare efficacy and outcome of daily saline irrigation versus saline/gentamicin for treating chronic rhinosinusitis (CRS). STUDY DESIGN: Prospective, randomized, double-blinded study. METHODS: Forty children diagnosed with CRS were enrolled. Patients were randomized to once-daily irrigation with saline or saline/gentamicin for 6 weeks. Treatment outcomes were measured using 1) Lund-Mackay scoring system of pre- and post-treatment computer tomography (CT); and 2) Sinonasal Quality-of-Life Survey (SN-5) completed at baseline, and after 3 weeks and 6 weeks of irrigation. RESULTS: Thirty-four patients completed the study and follow-up. There were statistically significant improvements in quality-of-life (QoL) scores after 3 weeks of irrigation within both groups. However, there were no statistically significant differences in the SN-5 scores between the two treatment groups after 3 and 6 week (P = .067). CT scores for each sinus and total scores were reduced for both groups after 6 weeks, and the differences in scores were statistically significant within each group after treatment, but there were no differences between the two treatment groups. Only one patient required functional endoscopic sinus surgery due to persistent symptoms. Compliance was over 90% for once daily irrigation over the 6 week treatment period. CONCLUSIONS: Once-daily intranasal irrigation for 6 weeks is safe and equally effective in the treatment of pediatric CRS using saline or saline plus gentamicin, and QoL was significantly improved after 3 weeks of irrigation in both groups. High tolerance, compliance, and effectiveness of irrigation support its use as a first-line treatment for pediatric CRS before considering surgical intervention.

Management and prevention of endotracheal intubation injury in neonates.

PURPOSE OF REVIEW: To summarize the diagnosis, pathology, and management of glottic, subglottic, and tracheal injuries secondary to endotracheal intubation in neonates. RECENT FINDINGS: Published reports of intubation-related injuries include laryngeal stenosis, subglottic stenosis (SGS), tracheal rupture, subglottic cysts, and pharyngoesophageal perforation. Such injuries are multifactorial, with risk factors including patient size and weight, use of cuffed versus uncuffed endotracheal tubes, and fragility of the mucosa. In addition, the skill and awareness of the person performing the intubation may also influence risk of intubation-related injuries. Studies on fetal cricoid anatomy demonstrate differences in the configuration of cricoids lumen between premature infants and the adult larynx. Most recently reported airway injuries due to intubation have history of prematurity as a common risk factor, with increasing incidence associated with decreasing gestational age and weight. Prematurity and prolonged intubations remain the top risk factors for development of subglottic cysts. Management of above-mentioned complications includes endoscopy versus open laryngotracheoplasty for SGS, using balloon or traditional dilatation or augmentation with cartilage grafts, respectively; bridging injured area with endotracheal tube versus open resection and primary closure for tracheal rupture; and use of laser or cold techniques for removal of cysts. SUMMARY: Although intubation-related injuries may occur in anyone, neonates are at increased risk due to their small airway lumen and cricoids cartilage morphology. Endoscopic and open reconstructive techniques increase treatment options to treat glottic and SGS.

Demographics and microbiology of otorrhea through patent tubes failing ototopical and/or oral antibiotic therapy.

OBJECTIVES: Posttympanostomy tube otorrhea (PTTO) results in significant health care cost and decreased satisfaction with care. The authors reviewed PTTO failing initial ototopical and/or oral antibiotic therapy and microbiology/susceptibility data from cultures. STUDY DESIGN: Case series with chart review. SETTING: A community university satellite ambulatory clinic and the outpatient clinic of a children's hospital. METHODS: Review of 202 patients with 228 discrete episodes of culture-positive otorrhea from January 2004 to January 2009. RESULTS: PTTO occurred an average of 13 months after tube placement. Median otorrhea duration was 21 days (mean, 42 days). A mean of 1.6 visits (range, 1-6) to the pediatric otolaryngology office was required for PTTO resolution. Ototopical therapy was reported used in 198 of 228 (87%) episodes of otorrhea prior to pediatric otolaryngology visit. Nearly 50% of patients were prescribed at least 1 or more courses of systemic antibiotics. Staphylococcus aureus accounted for 52% of the organisms cultured, with 57% methicillin-resistant S aureus (MRSA). S aureus resistance to clindamycin was high (49%) and resistance to levofloxacin was low (1.8%). MRSA was 68% clindamycin resistant, much higher than both ours and the children's hospital's clindamycin resistance rate of MRSA cultured from all other body sites. CONCLUSIONS: PTTO that presents as having failed ototopical and/or oral antibiotics most commonly consists of S aureus, Streptococcus pneumoniae, and Pseudomonas aeruginosa. MRSA is highly prevalent in this population. It is not necessary to culture PTTO that presents to an otolaryngology office, as resistance to levofloxacin was only 1.8%. It is unclear why the same fluoroquinolone ototopical therapy that failed initially is often successful in treating PTTO after otolaryngologist visit.

Practice patterns after tracheotomy in infants younger than 2 years.

OBJECTIVES: To report survey results of members of the American Society of Pediatric Otolaryngology (ASPO) on the practice patterns of surveillance endoscopy and management of suprastomal granuloma (SSG) in children younger than 2 years with indwelling tracheostomy tubes and to review our internal practice patterns. PATIENTS: All patients younger than 2 years who underwent tracheotomy between 1996 and 2006 at a tertiary children's hospital. INTERVENTIONS: (1) Retrospective medical chart summary and (2) ASPO-approved and -administered online surveys to the membership of a 14-question survey on indications for infant tracheotomy, indications for bronchoscopy after tracheotomy, and treatment preferences for SSG in this population. MAIN OUTCOME MEASURES: Summary and findings of survey results and of data collected from medical chart review, including demographics, medical comorbidities, age at time of tracheotomy, indications for tracheotomy, frequency of bronchoscopy after tracheotomy, frequency of observed SSG, and interventions for SSG. RESULTS: Seventy-five ASPO members completed the online surveys. Practice patterns varied for frequency of bronchoscopy: only as needed, every 12 months, every 6 months, and every 3 months were reported by 38% (n = 26), 25% (n = 17), 24% (n = 17), and 9% (n = 6) of ASPO members, respectively. Most important indications for bronchoscopy were preparation for laryngotracheal reconstruction and decannulation (100% [n = 65] and 92% [n = 60], respectively), bleeding (76% [n = 59]), and difficult tracheostomy tube changes (70% [n = 57]). Lumen obstruction of 25% to 50% and 50% to 75% by SSG would likely receive intervention (30% [n = 22] and 14% [n = 11], respectively) with skin hook eversion and removal being the most popular technique. We reviewed the medical records of a total of 201 infants who underwent tracheotomy at our institution (110 boys [54.7%]). Indications included ventilator dependence (32.2%), craniofacial anomaly (15.0%), cardiopulmonary insufficiency(15.0%), neuromuscular indication (15.0%), and subglottic stenosis (6.7%). Thirty patients (14.9%) were premature (mean gestational age, 27 weeks). Median age at time of tracheotomy was 4 months for premature infants and 3 months for term infants. Practice patterns regarding endoscopy and SSG management varied widely within our own institution. A total of 205 bronchoscopies were performed on 109 patients during the study period. At the time of first bronchoscopy 43 of 109 patients were noted to have an SSG (39.4%). Elective removal of SSG occurred in 20 of 43 cases (46.5%), and 9 of 20 patients were noted to have recurrent SSG at subsequent endoscopy (45%). In addition, of the 23 children who did not have intervention for their SSG, 15 of 23 had spontaneous resolution and no appreciable SSG at the time of follow-up endoscopy (65.0%). CONCLUSIONS: There are currently various practice patterns for surveillance endoscopy and management of SSG in children younger than 2 years with indwelling tracheostomy tubes. Development of clinical practice guidelines on this topic may improve patient care and reduce unnecessary procedures.

Weight gain after tonsillectomy: myth or reality? Interpreting research responsibly.

Excessive weight gain after tonsillectomy has been described by a handful of studies since as early as 1988 and, in recent years, mostly with variable study design, methods, and baseline weight of the subjects. Although most otolaryngologists have likely been asked whether tonsillectomy may lead to weight gain by parents and caretakers, there has been very limited research on this issue, and certainly no causal effect has been established by existing research. Awareness and counseling based on what has been described are relevant as a part of preoperative counseling. However, it is critical that our national epidemic of excessive weight gain in children and adolescents not be simply reduced to a matter of tonsillectomy but be understood as a multifactorial and complex issue. To study this topic well requires commitment to well-designed studies assessing caloric intake and expenditure, metabolic changes, and prospective growth measurements. Mechanisms for weight gain, even if excessive during the 12 months after tonsillectomy surgery, are far from being elucidated.